Skip to main content

Trauma patients with prehospital Glasgow Coma Scale less than nine: not a homogenous group

European Journal of Trauma and Emergency Surgery volume 46, pages 873–878 (2020)Cite this article

Abstract

Purpose

Prehospital guidelines stratify and manage patients with Glasgow Coma Scale (GCS) less than nine and any sign of head injury as affected by severe traumatic brain injury (STBI). We hypothesized that this group of patients is so inhomogeneous that uniform treatment guidelines cannot be advocated.

Methods

Patients (2005–2012) with prehospital GCS below nine and abbreviated injury scale head and neck above two were identified from trauma registry. Patients with acute lethal injuries, isolated neck injuries, extubated within 24 h or transferred interhospitally were excluded. Patients were dichotomized based on the worst prehospital GCS (recorded before sedatives) into two groups: GCS 3–5 and GCS 6–8. These were statistically compared using univariate analysis.

Results

The GCS 3–5 group (99 patients) when compared with the GCS 6–8 group (49 patients) had shorter prehospital times (63 vs. 79 min; p < 0.05), more frequent episodes of both hypoxia (30.3% vs. 7.7%; p < 0.05) and hypotension (26.7% vs. 6.4%; p < 0.05), more often required craniectomy (15.1% vs. 4.0%; p = 0.05) and higher mortality (33.3% vs. 2%; p < 0.05). In the GCS 3–5 group, prehospital endotracheal intubation was attempted more often (57.5% vs. 28.6%, p < 0.05) and was more often successful (39.3% vs. 10.2%; p = 0.05). Length of stay in ICU did not differ.

Conclusions

STBI patients are fundamentally different based on whether their initial GCS falls into 3–5 or 6–8 category. Recommendations from trials investigating trauma patients with GCS less than nine as one group should be translated with caution to clinical practice.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

Abbreviations

AIS H/N:

Abbreviated injury score head and neck

GCS:

Glasgow Coma Scale

ED:

Emergency department

ETI:

Endotracheal intubation

EVD:

External ventricular drain

ICP:

Intracerebral pressure monitor

ICU:

Intensive care unit

ISS:

Injury severity score

STBI:

Severe traumatic brain injury

References

  1. Evans JA, van Wessem KJ, McDougall D, Lee KA, Lyons T, Balogh ZJ. Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg. 2010;34:158–63.

    Article  Google Scholar 

  2. Franschman G, Peerdeman SM, Andriessen TM, Greuters S, Toor AE, Vos PE, et al. Effect of secondary prehospital risk factors on outcome in severe traumatic brain injury in the context of fast access to trauma care. J Trauma. 2011;71:826–32.

    Article  Google Scholar 

  3. Kerby JD, Cusick MV. Prehospital emergency trauma care and management. Surg Clin N Am. 2012;9:823–41.

    Article  Google Scholar 

  4. Battjadia N, Carney N, Crocco T, Fallat ME, Hennes HMA, Jagoda AS, et al. Guidelines for prehospital management of traumatic brain injury, 2nd edn. Prehosp Emerg Care. 2008;12(Suppl 1):S1–52.

    Google Scholar 

  5. Hoogmartens O, Heselmans A, Van de Velde S, Castrén M, Sjölin H, Sabbe M, Aertgeerts B, Ramaekers D. Evidence-based prehospital management of severe traumatic brain injury: a comparative analysis of current clinical practice guidelines. Prehosp Emerg Care. 2014;18:265–73.

    Article  Google Scholar 

  6. Mayglothling J, Duane TM, Gibbs M, McCunn M, Legome E, Eastman AL, et al. Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the surgery of trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S333–40.

    Article  Google Scholar 

  7. Yeh DD, Velmahos GC. Prehospital intubation for traumatic brain injury: do it correctly, or not at all. ANZ J Surg. 2012;82:484–5.

    Article  Google Scholar 

  8. Karamanos E, Talving P, Skiada D, Osby M, Inaba K, Lam L, et al. Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis. Prehosp Disaster Med. 2014;29:32–6.

    Article  Google Scholar 

  9. Haltmeier T, Schnüriger B, Benjamin E, Maeder MB, Künzler M, Siboni S, et al. Isolated blunt severe traumatic brain injury in Bern, Switzerland, and the USA: a matched cohort study. J Trauma Acute Care Surg. 2016;80:296–301.

    Article  Google Scholar 

  10. Bochicchio GV, Ilahi O, Joshi M, Bochicchio K, Scalea TM. Endotracheal intubation in the field does not improve outcome in trauma patients who present without an acutely lethal traumatic brain injury. J Trauma Acute Care Surg. 2016;80:296–301.

    Article  Google Scholar 

  11. Gomez D, Byrne JP, Alali AS, Xiong W, Hoeft C, Neal M, Subacius H, Nathens AB. Inclusion of highest glasgow coma scale motor component score in mortality risk adjustment for benchmarking of trauma center performance. J Am Coll Surg. 2017;225:755–62.

    Article  Google Scholar 

  12. Reith FCM, Lingsma HF, Gabbe BJ, Lecky FE, Roberts I, Maas AIR. Differential effects of the Glasgow Coma Scale Score and its components: an analysis of 54,069 patients with traumatic brain injury. Injury. 2017;48:1932–43.

    Article  Google Scholar 

  13. Murray GD, Brennan PM, Teasdale GM. Simplifying the use of prognostic information in traumatic brain injury. J Neurosurg. 2018;128:1612–34.

    Article  Google Scholar 

  14. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2:81–4.

    CAS  Article  Google Scholar 

  15. Bernard SA, Nguyen V, Cameron P, Masci K, Fitzgerald M, Cooper DJ, Walker T, Std BP, Myles P, Murray L, David Taylor, Smith K, Patrick I, Edington J, Bacon A, Rosenfeld JV, Judson R. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg. 2010;252:959–65.

    Article  Google Scholar 

  16. Garner AA, Mann KP, Fearnside M, Poynter E, Gebski V. The head injury retrieval trial (HIRT): a single-centre randomised controlled trial of physician prehospital management of severe blunt head injury compared with management by paramedics only. Emerg Med J. 2015;32:869–75.

    Article  Google Scholar 

  17. Nichol A, Gantner D, Presneill J, Murray L, Trapani T, Bernard S, Cameron P, Capellier G, Forbes A, McArthur C, Newby L, Rashford S, Rosenfeld JV, Smith T, Stephenson M, Varma D, Walker T, Webb S, Cooper DJ. Protocol for a multicentre randomised controlled trial of early and sustained prophylactic hypothermia in the management of traumatic brain injury. Crit Care Resusc. 2015;17:92–100.

    PubMed  Google Scholar 

  18. Bulger EM, May S, Brasel KJ, Schreiber M, Kerby JD, Tisherman SA, Newgard C, Slutsky A, Coimbra R, Emerson S, Minei JP, Bardarson B, Kudenchuk P, Baker A, Christenson J, Idris A, Davis D, Fabian TC, Aufderheide TP, Callaway C, Williams C, Banek J, Vaillancourt C, van Heest R, Sopko G, Hata JS, Hoyt DB, ROC Investigators. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: a randomized controlled trial. JAMA. 2010;304:1455–64.

    CAS  Article  Google Scholar 

  19. Wright DW, Yeatts SD, Silbergleit R, Palesch YY, Hertzberg VS, Frankel M, Goldstein FC, Caveney AF, Howlett-Smith H, Bengelink EM, Manley GT, Merck LH, Janis LS, Barsan WG, NETT Investigators. Very early administration of progesterone for acute traumatic brain injury. N Engl J Med. 2014;371:2457–66.

    Article  Google Scholar 

Download references

Funding

None.

Author information

Affiliations

  1. Department of Traumatology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia

    Cino Bendinelli, Dominic Ku, Kate Louise King, Shane Nebauer & Zsolt Janos Balogh

Authors
  1. Cino Bendinelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Dominic Ku
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kate Louise King
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Shane Nebauer
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zsolt Janos Balogh
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

CB contributed to data interpretation and writing. DK performed data collection, data analysis and data interpretation and writing. KK helped in data collection and data interpretation. SN performed literature search and data collection. ZJB contributed to study design, writing and critical revision. All authors have read and approved the manuscript

Corresponding author

Correspondence to Zsolt Janos Balogh.

Ethics declarations

Conflict of interest

Cino Bendinelli, Dominic Ku, Kate Louise King, Shane Nebauer, Zsolt Janos Balogh declare that they have no conflict of interest.

Ethics approval and consent to participate

The protocol was approved by the Hunter New England Human Research Ethics Committee (09/12/16/5.01). Being a retrospective study with de-identified data, the need for patient approval to participate was waived.

Availability of data and material

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bendinelli, C., Ku, D., King, K.L. et al. Trauma patients with prehospital Glasgow Coma Scale less than nine: not a homogenous group. Eur J Trauma Emerg Surg 46, 873–878 (2020). https://doi.org/10.1007/s00068-019-01139-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-019-01139-9

Keywords

  • Glasgow Coma Scale
  • Traumatic brain injury
  • Prehospital
  • Paramedic
  • Intubation